As a Radiology Transcriptionist, you will be responsible for proofreading and helping to correct radiology report language generated using speech AI models, error correction models, and other generative AI tools. You'll work closely with one of our CMIOs and the Reporting team to ensure report language is accurate, complete, and adheres to national clinical guidelines.

Evaluates health record documentation and charges to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support the outpatient visit. Ensures that data complies with regulatory and coding guidelines. Reviews medical information, such as diseases or symptoms and diagnostic descriptions and procedures for a given visit, to accurately assign and sequence the correct ICD-10 CM, HCPCS and CPT codes. Adheres to the quality and productivity standards set by the department.

Abstracts specific patient information from a range of resources, including medical records, and codes information into a database according to prescribed protocol, maintaining and editing data for accuracy and completeness. Maintains record keeping systems and procedures for clinical studies. All employees are responsible for extending the mission and values of Baltimore Washington Medical Center.

Accurately abstract information from the medial records into the appropriate coding systems, ensuring compliance with established guidelines. Determine the most appropriate diagnosis after a thorough review of the medical records. Work closely with practice staff with regards to coding and assignment of a MS-DRGs (Diagnosis Related Group) and APCs (Ambulatory Payment Classification).

Under direct supervision, accurately codes hospital inpatient accounts for the purpose of appropriate reimbursement, research, statistics and compliance to federal and state regulations in accordance with established ICD-10-CM/PCS coding classification systems. The coder serves as a clinical coding subject matter expert, and utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed. They also analyze, code and abstract complex inpatient cases such as trauma, rehab, neurology, critical care, etc. utilizing the ICD-10-CM and ICD-10-PCS nomenclature to ensure accurate APR-DRG/SOI/ROM and POA assignment.